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Aortic Proximalisation -- Zone 0 vs. Zone 2. A Concept or True Challenge?
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  • Cian Tan,
  • Aleksandra Lopuszko,
  • Wahaj Munir,
  • Mohamad Bashir,
  • Benjamin Adams
Cian Tan
Queen Mary University of London Barts and The London School of Medicine and Dentistry
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Aleksandra Lopuszko
Queen Mary University of London Barts and The London School of Medicine and Dentistry
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Wahaj Munir
Queen Mary University of London Barts and The London School of Medicine and Dentistry
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Mohamad Bashir
NHS Wales Health Education and Improvement Wales
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Benjamin Adams
Barts Health NHS Trust
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Abstract

Background Use of the Frozen Elephant Trunk (FET) device to manage complex surgical pathologies of the aorta (e.g. acute Type A aortic dissection) has gained popularity since its introduction in the early 2000s. Though the distal anastomosis was traditionally performed at Zone 3 (Z-3-FET), preference gradually shifted towards Zone 2 (Z-2-FET) in favour of improved surgical access and outcomes. This review seeks to elucidate whether proximalisation of arch repair to Zone 0 (Z-0-FET) would further improve postoperative outcomes. Methods We performed a review of available literature to evaluate the comparative efficacies of Z-2-FET versus Z-0-FET, in terms of surgical technique, clinical outcomes, and incidence of adverse events. Results Z-0-FET seems to be associated with a more accessible surgical approach, and shorter cardiopulmonary bypass, antegrade cerebral perfusion, and cardioplegia durations than Z-2-FET. Further, Z-0-FET is could potentially be associated with a lower incidence of neurological, renal, and recurrent laryngeal nerve injury, as well as mortality and reintervention rates than Z-2-FET. This said, Z-0-FET is itself associated with significant challenges, and efficacy in terms of postoperative true lumen integrity and false lumen thrombosis is mixed. Conclusion Current literature seems to suggest that Z-0-FET procedures are more straightforward and associated with lower rates of certain adverse events, however, the majority of data reviewed is retrospective. This review therefore recommends prospective research into the comparative strengths and limitations of Z-0-FET and Z-2-FET to better substantiate whether proximalisation of arch repair represents a concept, or a true challenge to advance surgical intervention for arch pathologies.

Peer review status:ACCEPTED

24 May 2021Submitted to Journal of Cardiac Surgery
25 May 2021Assigned to Editor
25 May 2021Submission Checks Completed
25 May 2021Reviewer(s) Assigned
01 Jun 2021Review(s) Completed, Editorial Evaluation Pending
01 Jun 2021Editorial Decision: Accept